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Years ago I was teaching a client on the reformer when I suggested she try the Short Spine for the first time. She looked at me with horror and said “I can’t do that – I have a herniated disc!” Now it was my turn to look at her with horror as my mind raced – had I seen any signs of this since she came in the studio – why didn’t I know this? I assumed it had happened within the week’s time since she’d last visited so I said “My God! When did that happen?” And she replied “About six years ago.”
So let that sink in – this woman had had a diagnosis six years ago, that she’d been carrying around with her since then like a life sentence. All that time, she had consciously avoided certain movements (although in all likelihood had been in the positions that would aggravate a herniation in her sleep, putting on shoes, driving her car etc.). She still believed certain movements were off the table (or reformer, in this case).
So is a herniated disc a life sentence? What is a herniated disc? For that matter, can a disc slip? Let’s talk about Disc Hernation!
Anatomy of a Disc
I’ve asked clients what they think a disc is like and most people use the jelly doughnut analogy – where the disc is the doughnut and the nucleus is the jelly. The image suggests a soft liquid easily moved through an unresistant dough. But this is not actually the case – you are much more resilient than that. Otherwise, day-to-day movements of the spine would commonly result in hernias.
In fact, the nucleus polposus (middle of the disc) is more like “heavy phlegm”. The annulus polposus (outer layer of the disc) is a collagen fibre tissue that is obliquely oriented from the inside out, each subsequent layer running in the opposite direction which makes it incredibly strong but also able to be somewhat porous and to change length in various planes. It is anchored into the ends of the vertebral bodies and also to the edge of the vertebra’s stiffer bone. This results in material that has the ability to withstand normal spinal segmental movements such as extension, flexion and rotation.
The vertebrae themselves have strong sides (like a barrel) but their tops and bottoms are more deformable cartilage (called an “end plate”) that allows the disc material to anchor into the end plate. It is thinner in the middle than at the sides, and is porous to enable transfer of nutrients into the vertebra. The inside of the body of the vertebra is filled with bone tissue with a mesh-like structure containing many pores called cancellous bone. Incredibly, under compression, the nucleus of the disc causes the end plate to bulge inward, pressing on this cancellous bone, which fails first. In other words, it is more common for the porous bone of the body of the vertebra to fracture than it is for the disc to herniate. In fact, it is hypothesized that this is happening as the vertebrae absorb shock from movement (originally thought to be a function of the disc only!).
This allows for deformation of the vertebra (that sounds like a bad thing, but your bones need to be able to deform under load to a certain extent as a part of their natural function). So the little bridges that form the cancellous bone of the body of the vertebra are essentially capable of breaking and remodelling. This is called “microfracture” or “microdamage.” These are not clear on xrays.
“Damaged cancellous fractures appear to heal quickly, given the small amount of osteogenic activity needed, at least when compared with the length of time needed to repair collagenous tissues.”
This of course is in a healthy, non-osteoporotic spine.
So we have endplate fractures, and microfracture of the cancellous bone within the body of the vertebra. What does that have to do with disc herniation? I’m getting there!
So here’s something I bet you didn’t know – if the end plate fractures, it’s possible that the nucleus of the disc can squirt through the end plate into the vertebral body! This can be thought of as a vertical herniation and the annulus remains intact. This typically occurs during compression in a neutral position (i.e., not bent forwards or backwards – decades of riding sitting trot on bouncy horses comes to mind!).
If the nucleus is squirted into the vertebra, the actual disc will become flatter, and this is often misdiagnosed as degenerated disc or herniated disc. If the space between vertebral bodies is decreased in this manner, it’s possible that nerve root space is compromised. Thus, this can be as painful an experience as “true herniation.” It does not always result in pain.
Often people receive imaging after an event and it shows evidence of herniation or other such spinal pathology. It is then surmised that the event produced the pathology but often these things take a long time to happen and it’s a repetitive loading that results in an eventual failure. It’s often the case when receiving imaging that you will see possible explanations for pain, when it’s not necessarily true that the pathology is the source of pain. That can be very misleading and confusing. And of course, if you do have imaging that shows herniation, it is going to change the way you think and move! The reverse is also true, people who are asymptomatic (i.e, have no pain) and get imaging also often show disc and vertebral pathologies which are considered a normal process of aging.
It is still not known with certainty how discs herniate. The best prevailing theories are annulus delamination and cell death. There does seem to be some things in common with all disc herniation.
Annulus Delamination – the oblique layering of the annulus fibres called the laminae become separated, creating a pathway which allows nucleus material to “worm” its way through the layers until it extrudes through the back or side creating a herniation.
Cell Death and Lack of Health – a healthy disc builds pressure that is so high that nerves or blood vessels can’t survive (discs themselves are not normally vascularized). But if end plates fracture, the disc can no longer create that kind of pressure and “degenerated discs” can have nerves and blood vessels invade the disc (which also explains the ability to generate pain).
So discs don’t slip – the entire structure is pretty well rooted to the adjoining vertebrae, but the material within the disc can extrude and the disc itself can become flatter.
What Most Herniations Have in Common
– Discs must be bent to the full end range of motion in order to herniate
– Disc herniation is associated with extremes of posture plus repeated loading
– there is a link between herniation and sedentary postures such as prolonged chair sitting
– herniation occurs in younger spines
Can they HEAL?
In a word, yes.
… although a variety of anecdotal as well as Level IV–V evidence exists, suggesting that 90% of patients with lumbar disc herniations will resolve their symptoms without substantial medical intervention.
A massive disc herniation can pursue a favourable clinical course. If early progress is shown, the long-term prognosis is very good and even massive disc herniations can be treated conservatively.
Most patients suffering from radiculopathy caused by intervertebral disc herniation heal spontaneously without surgical intervention.
There are plenty of studies and anecdotal evidence that herniations can resolve. In fact, I’ve had several instances of herniation myself, and have a very robust, healthy and pain free spine with no recurrence since about 2012.
So what happened to my client? She went on to do the Short Spine exercise; pain-free and with great happiness and ability. This gave her the freedom to move in all the ways her spine was designed to with confidence, and restored the idea that her spine was not inherently vulnerable.
 McGill, Low Back Disorders 44
 McGill, Low Back Disorders 38
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